Penile Rehabilitation In The Radical Prostatectomy Patient

Main Category: Urology / Nephrology
Also Included In: Prostate / Prostate Cancer
Article Date: 28 Jun 2008 - 1:00 PDT

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ORLANDO, FL (UroToday.com) - Dr. Ira Sharlip moderated a debate on penile rehabilitation. A consequence of radical prostatectomy (RP) is ED and its prevalence is reported between 9-93%. How penile rehabilitation is given and whether it works is debated. The purpose of penile rehabilitation is to provide oxygen to the corpora cavernosa for both prevention and recovery in post-RP patients.

Dr. Mulhall said the purpose of penile rehabilitation is to prevent structural alterations to maximize chance of a man returning to his preoperative sexual performance. Minor neuropraxia results in vascular, neural and smooth muscle injury. The erect penile state and oxygenation turns off TGF-beta and decreases collagen production. Hyperbaric oxygen and cavernosal nerve injury had improved return of erectile function compared to controls in a rat experiment. The later men present with their ED post-RP the worse their venous leak problem and resultant structural changes and fibrosis in the penis. Early use of PDE5 inhibitors preserves penile processes in animal models. In 3 clinical trials injection therapy and sildenafil improved erectile response. Biopsies of penile tissue at 6 months post-RP in men treated with PDE5 inhibitors had preservation of smooth muscle content. Smooth muscle preservation in both the corpora and endothelium are the reasons that penile rehabilitation makes sense, he concluded.

Dr. Donatucci argued that the body of evidence supporting penile rehabilitation may not be presently available. Effect in animals does not equate with the same response in humans, and only focuses on a specific mechanism not the entire system. Nerve sparing is not a standardized event and there is a lack of standardized algorithms. Outcomes at specific centers can not be translated to general populations. He showed clinical trials that were not positive between on-demand and daily use of PDE5 drugs. There are 7 ongoing trials for penile rehabilitation. Most are single investigator and not multi-center. Some are in radiotherapy patients and not surgical series. He stated that there is not enough evidence to support penile rehabilitation in an evidence-based fashion at the present time.

Dr. Mulhall rebuttaled that the lack of level 1 evidence based medicine does not mean that we shouldn't practice penile rehabilitation. Most studies in ED are a translation from animal models, so he refuted that. ED is associated with depression and reduced QOL and the practice is used by 87% of the members of the Society of Sexual Medicine.

Dr. Donatucci countered that we must be careful about the nuances of how our literature is interpreted by the public. Outcomes of specific trials can not be translated to all affected patients, he concluded.

Moderated by Ira D. Sharlip, MD, at the Annual Meeting of the American Urological Association (AUA) - May 17 - 22, 2008. Orange County Convention Center - Orlando, Florida, USA.

Reported by UroToday.com Contributing Editor Christopher P. Evans, MD, FACS

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